Iceni House

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Feedback from relatives was mostly positive and relatives reported an improving culture. Health care professionals commented that the service had not been without its challenges but felt communication particularly amongst the senior management team was much improved. Health care professionals felt risks associated with people’s care were mitigated through joint working with other health care professionals which included regular multidisciplinary health meetings and intensive older people support teams. Family members felt the manager was quick to notice changes in people’s needs and communicated this. The incident of falls was much higher on the Pickenham unit, and this was attributed to people being mobile and having freedom to move around. Equipment such as sensor mats were in place to try and reduce risk levels, but the analysis of falls was not clearly linked to staffing levels, and we observed a lack of staff in communal areas which placed people at a higher level of risk. Personal records were not robust. For example, we saw a significant injury for a person who had fallen off the sofa when asleep, but it was not clear from their falls risk assessment what was in place to support them to maintain safe routines and go to bed in the evenings. Another person’s records indicated gaps in their eating where they would refuse food and it was not clear how this was followed up. The same was true for their personal care and risks of self-neglect as staff were not recording daily what support they had received with personal care and one entry indicated they were self-care which contradicted other records.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager was developing and sustaining a learning culture in which incidents were reviewed and shared. The registered manager also encouraged feedback about the service in order to improve the culture and care but had not completed a whole service audit this service this year to gain everyone’s feedback about what was working well, and improvements needed. We found peoples experiences had varied over time and felt people had not always received a consistently good service. When we fed back concerns about the dementia suite and the lack of leadership and escalation of concern by members of staff the manager and nominated individual were surprised. They said their greatest challenge had been on the first floor, the residential suite. We felt people on the first floor were more able to express themselves where people living downstairs would not be able to voice their concerns. According to staff spoken with there were less visitors on the ground floor and there were no volunteers or access to voluntary organizations. This left them people vulnerable to poor care as they were not able to contribute to their care and were reliant on staff to anticipate their needs. We found staff did not anticipate or respond to people’s needs in appropriate ways. For example, we observed one person distressed and looking for a relative. We were able to acknowledge their distress but did not observe staff providing any reassurance. Audits helped to identify the culture in the service and ensure staff were delivering person centred care. However during our inspection we did not find this culture fully embedded which meant some peoples experiences were not as rich as they could be or in line with their needs. More detailed record keeping would help us to understand how risks were being followed up and escalated.

Most staff spoken with felt the service was improving and there was effective management in place. Most but not all staff said they were able to raise concerns, and these were acted upon. Leaders had put systems in place to help ensure communication was more effective such as weekly management meetings, daily briefing sessions and resident of the day. We felt however these were not always effectively working such as resident of the day, heads of department were not always recording their discussions with people or identifying issues.

Processes were in place to audit the service and collate incidents and other risks associated with falls, safeguarding concerns etc. Records inspected were poor and not updated in an appropriate way. This did not assure us that staff would have a good understanding of people’s needs and risk associated with their care, particularly where needs had changed. This was particularly the case for people recently moving to the service. For example, one person’s record showed intermittent patterns of eating and no base line recording of their preferred routines and when and how often they liked to eat. Where risks were recorded there was no clear escalation or review of that risk.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We spoke with 18 relatives in total. All were aware of how to contact the manager, escalate concerns and the role of the local authority safeguarding team. They said the manager went out of his way to ensure they all knew what to do when something went wrong, or they had concerns about the care and treatment people were receiving. Relatives said the manager was proactive in addressing their concerns and acting immediately if poor practice was identified. Several relatives had concerns about the care received to their family member, both related to staffing levels and one to the lack of social experience and isolation. People had opportunities to attend meetings but limited opportunities to influence the service delivery and we were not assured how ‘resident of the day’ was used to inform wider home improvements. Some relatives and people spoken with raised concerns about people entering other people’s rooms uninvited. For example, one said, “My partner does hallucinate and gets worried by other residents wandering into his room. The staff come and move them on, but it should not really happen.” As an observation we noted room doors were painted in different colours and toilet/bathroom were clearly marked but there was no object of reference on people’s doors which might help them distinguish their room. This may help to orientate people and we strongly felt staff should be visible in communal areas to help reduce risks to everyone using the service. We noted on several occasions staff were all together in the office and therefore did not have good oversight of what was happening in other parts of the home.

The registered manager was aware of how and when to contact the local authority to report safeguarding concerns. They were on the Norfolk adult safeguarding board and both the GP practice, and the local authority said the manager was proactive in raising/dealings with concerns and escalating things when the outcome was not satisfactory. Although this was not a nursing home relatives felt their family member benefitted hugely from having a nurse on site and all his clinical knowledge. Staff mostly said they were confident to raise issues, one member of staff said, “No concerning practices. I am happy to raise things internally with confidence they will be actioned.” We however had concern around staffing practice which had resulted in staff dismissal but we still felt there was a culture where some staff failed to thrive. For example during our site visit there was a lack of leadership and staff were not working to high standards to uphold and maintain people’s needs.

During our inspection we raised concern about an incident that occurred between two people and this either went unnoticed or unchallenged due to the levels of supervision within the home. We did feel people were at increased risk when left unsupervised although no one received 1-1 support. Several people became upset with other people’s behaviour which led to verbal and physical reactions. We felt primarily people were safe and staff knew how to escalate concerns and felt these would be acted upon but were concerned that people relied on staff to keep them safe and staff were not sufficiently responsive.

CQC and the local authority were advised of safeguarding concerns as appropriate but follow up information was not always received as safeguarding concerns sometimes took along time to resolve. Incidents were kept under review and actioned. There had been a robust response to whistleblowing concerns. Information had been shared as appropriate.

Relatives were mostly confident about how risks were communicated and acted upon and most spoke about good security. However, we did not see a detailed analysis if fluctuating staffing levels contributed to the risk of falls and incidents between people. Through our own observations we felt risk did increase at times when staff were not present in communal areas. There were observed and reported incidents of people going into other people’s rooms uninvited, which one person described as ‘very frightening.’ There were minor altercations between people including one person slapping another and one person shouting at others. We also noted mealtime was poorly supervised on the dementia suite which could have resulted in an increased risk of choking, scolding from hot soup/ drinks or some people missing their meals all together. It was difficult to assess the management of risk because we found records poor. There was not a clear escalation plan for example when a person had not eaten well for a few days, or when fluids were low. We did not see fluid targets on people’s fluid records or actions taken when fluids were low. The manager had explained to staff the importance of record keeping and there was clear guidance for staff to follow. However, staff reported the current record system to be cumbersome and repetitive. Almost all relatives reported that falls had occurred, but all said safety was taken seriously and pressure mats, bedrails and CCTV all helped to keep their family member safe. They also said referrals to the falls team were made which was confirmed by health care professionals. Following our observations we asked if CCTV extended to the dining area where we observed several incidents. It did not and this is being addressed. We are currently reviewing an incident involving a fall resulting in injury.

The registered manager told us they maintained oversight of the floors and were visible across the day to support staff. They also sent a range of audits for us to consider which included both a daily team briefing , handover records, and head of department meeting which we attended. The audits included people’s experiences such as dining room audits and oversight of people’s activity. Resident of the day was also in place. We were confidence that clinical needs were being addressed as far as possible with regular input from other professionals. Managers' surgeries for people using the service were held along with relatives forums, open forum meetings, and surveys were diarised throughout the calendar year . We had concerns that whilst the manager was there, he ran a ‘tight ship’ but in the absence of the manager staff were not deployed appropriately and were not seen to run an effective team on the day of our inspection. We understood however sickness impacted on peoples experiences on the day of inspection and some of the management in place were still addressing issues within the service.

Risks were mitigated from a well-established environment and equipment to help maximise people’s independence and alert staff to motion. CCTV was used in communal areas so incidents could be reviewed. The staffing dependency tool stated staff were always in lounges when people were present, this was not the case during our visit and staff were hard to find with people being left unsupervised. We identified a number of people had bouts of incontinence and in one instance this made the floor wet and therefore dangerous as people were walking in and out. The domestic staff when aware dealt with it quickly. We pointed out gloves were left out in communal areas and if swallowed would cause harm. Food snacks were also left out which we suggested might pose a risk where people had a swallowing difficulty. For example, we saw crisps and apples but the manager confirmed there was no immediate risks to people and gave people the option to graze. We would consider softer food might be more appropriate.

Communication was key to the success of the whole home and the early identification of risk. Structured systems had been established to help identify and have oversight of the whole home at any given time. Heads of department meetings and individual 1-1 and staff meetings helped to support staff and discuss care practices and risks. Some dynamics affected the stability and safety of the home such as staff vacancies, sickness, effective deployment of staff, and new admissions. All were at play at our recent inspection. However the registered manager advised the current sickness rate within the home was less than 5%. Recruitment had been successful with an emphasis on robust, safe recruitment and removing staff from the service when not suitable. Concerns about record keeping had been acknoweldged and the home were in the process of transfering to a digitalised records system.

We received a lot of comment about the environment in which people lived with most thinking it was suitable, nicely laid out and clean. One person told us it was the best care home in the area as they had their own shower. Relatives told us there were good standards of cleanliness although some mentioned overrunning maintenance issues. Concerns were raised about access to the garden particularly those living upstairs and not everyone being able to enjoy a nice view. Some people struggled with orientation and we observed people getting distressed and going in and out of rooms, in one case looking for a lost relative. Staff were not about to supervise and encourage people to join in with others. Several people told us they were isolated , one person had their door shut at all times due to concerns about their safety. This would of had an isolating effect on them. Another person told us about their social isolation and relied on staff to provide companionship as they did not leave their room due to physical health. We noted many areas of the home were under utilized.

We observed people moving around freely without restriction. People on the residential suite upstairs were able to come downstairs and one person was going out which they could do independently. The environment offered enough space to accommodate peoples needs and there was no clutter and objects of reference were on the walls and on the table such as puzzles, pictures etc. The building was well maintained but we did identify pictures had been removed just leaving hooks and some bedrooms were very sparse which was down to individual family members.

Staffing levels fluctuated in line with people’s needs and dependency levels. We had some negative feedback about staffing from several relatives. Relatives said call bell waiting times could be slow and said at weekends there were less staff around. However, most relatives said staffing had improved and carers were better supported by the employment of more ancillary staff and wellbeing staff. Of the people we spoke with some said they had to wait at busy times of the day. During our visit we observed that some people needed assistance and when we flagged this up with staff, we were told they would have to wait, as staff were busy with other things. Call bell audits did not identify people waiting more than a few minutes but this would depend on when people used the call bell. In the case of the Pickenham suite most people would not be able to use a call bell and were dependent on staff checking them regularly. Most people on the Pickenham Unit were in their rooms across the day or unsupervised in the lounges, lunch time supervision was poor and there was a lack of social stimulation for people. Ordinarily there were be up to 2 staff providing activities but these were not observed on the day and 1 staff on each floor with more than 30 people to support would be an impossible task. Care staff would be expected to help provide activities but from our observations were busy throughout the day without a clear break. From the evidence we collated we identified a breach of regulation 18: Staffing of The Health And Social Care Act 2008 ( Regulated Activities )

The registered manager and nominated individual told us they used a dependency tool to identify if they had the right number of staff and this was reviewed regularly and in light of incidents etc. Whilst we do not dispute this feedback, we collated concerns about staffing and staff deployment. Developing the competencies of staff would assist in ensuring all staff were working effectively. Staff champions were being developed as were specific job roles but until this had been embedded, we had concerns about staff’s knowledge and approach with people living with dementia. One staff member told us “Personally, I feel there could be more staff, some days we are rushed off our feet, things do not get done as quickly as they could be. Residents do not really feel the impact, but staff are stretched and stressed.” Another said,” It is busy, and people are needing to wait longer.” Staff felt dependency had increased and this they openly discussed with management. Concerns about staffing levels and a manageable workload was expressed as a concern from staff working all shifts and not just an isolated comment.

During our site visit we noted people were not engaged outside of personal care tasks and felt the care observed was not person centred or in line with peoples needs. We were advised that unexpected sickness and holidays had created this situation. However, we spoke with many staff before the insepction who told us they were always busy on each shift, and they felt like there were not enough staff. The deployment of staff at lunch time and in communal areas was poorly managed and placed people at risks of receiving unsuitable care. For example we observed people ill dressed and unshaven. We observed altercations between people and we observed people walking away at meal time without being re-orientated or attempts made to reengage them. A number of people were eating in their rooms unsupervised and without interaction. By comparison the top floor was more organised with people observed as having their needs met. However feedback from a number of people on this floor indicated this was not always the case. One person gave a very negative view and we fed this back to the manager so they could intervene.

Staffing levels were kept under review and there were clear processes to do this. There was a dependency tool and other factors helped determine if peoples needs were being met. The registered manager confirmed that people were supported by other professionals as appropritae and referals were made when neccessary. Statutory reviews were the role of the local authority and the registered manager said these had been requested as appropriate. Concerns were raised as part of this inspection about staffing levels to which we gave extensive feedback. The manager told us they consulted with staff about staffing levels and would consider any evidence that staffing levels were insufficent.

Relatives were complimentary about the standards of cleanliness. One said, “They seem to keep them and the home really clean,” another said, “The cleaners are fantastic, they are constantly cleaning. “People’s rooms were personalised and kept clean. Domestic staff were observed working efficiently but we did have concerns about incontinence and the effect this could have on people’s safety. A number of wet floor signs were observed during our site visit with people walking across the floor. There was an odour on the dementia suite, and we had concerns about deep cleaning as we noted some of the chairs in the dining room were not clean and the floor was not clean either.

The registered manager was visible in the service and checked standards were maintained, this included cleaning across the service and was apologetic there was an odour on the day of the site visit but had agreed to have carpets replaced. Audits were in place to measure standards of cleanliness and we did observe domestic staff cleaning throughout the day and also interacting well with people as they went.

Cleaning took place across the day and good standards of hygiene were being maintained.

Infection control policies and procedures were in place and all staff received training in infection control. There were robust processes in place for dealing with outbreaks of infection to help ensure the spread of infection was controlled.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.